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Glossary of Medical and Mental Health Terms

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This glossary contains definitions for common medical terms, terms specific to mental health, acronyms that you may encounter when navigating the mental health system, and terminology specific to the managed care system.

201 Petition
A voluntary commitment that a person, 14 years or older, signs when he/she wants to be in the hospital voluntarily. With a 201, the person can leave the hospital after he/she gives notice that he/she no longer wants treatment. When the person signs a 201, he/she also signs a statement that he/she promises to give the hospital anywhere from 0 to 72 hours notice before he/she will leave.
302 Petition
An authorization for involuntary emergency evaluation for no more than 120 hours (5 days). Three people can authorize this: a County Mental Health Officer, a policeman, or a physician. The reasons for seeking a 302 are that a person exhibiting severe mental disability poses a present danger to self or others. The person will be taken to a hospital for an examination. At the hospital, a doctor decides whether the person needs hospitalization or not. If the person is not hospitalized he/she is returned to the community where he/she was picked up. If the hospital wants to keep the person for more than 120 hours it must file a 303.
303 Petition
A hearing held to determine if a person who has received a 302 should be committed. This hearing must be held within 120 hours of the person's admittance to the hospital. A commitment can be for a maximum 20 days.
304B Petition
This hearing is for a person who is in the hospital involuntarily on a 303 commitment. The 304B hearing must occur before the 20 days expire. The person can be committed for a maximum of 90 days on a 304B or be released.
Active Listening
People are actively listening when they respond to someone in a way that shows that they have listened to what the person has said and understand how the person feels and what they are saying about themselves. A helpful way to do this is for the listener, having heard what the speaker has said, to then repeat, in the listener's own words, what he or she thinks the speaker has said. The listener does not have to agree with the speaker -- he or she must simply state what they think the speaker said. This enables the speaker to find out whether the listener really understood. If not, the speaker can explain some more.
Another part of active listening is for the listener to reflect back the feelings that he/she heard from the speaker. For instance the listener might say, "It sounds to me that you felt angry or frustrated or confused when [a particular event] happened. Is that right?" The speaker, than can confirm or clarify how they feel. Often because of active listening, the speaker can feel that the listener understands, not only the facts of what happened but also the speaker's inner feelings about the matter.
Activities of Daily Living (ADL)
An index or scale which measures a patient's degree of independence in bathing, dressing, using the toilet, eating, and moving from one place to another.
Acute Care
Medical treatment rendered to individuals whose illnesses or health problems are of a short-term or episodic nature. Acute care facilities are those hospitals that mainly serve persons with short-term health problems.
Adult Protective Services (APS)
Adult Protective Services receives and investigates reports of abuse, neglect, and exploitation of elderly persons (defined as age 65 and older) and persons with disabilities.
American Psychological Association (APA)
The American Psychological Association in Washington, DC, is the largest scientific and professional organization representing psychology in the United States and is the world's largest association of psychologists.
American Public Human Services Association (APHSA formerly APWA)
The American Public Human Services Association is a nonprofit, bipartisan organization of individuals and agencies concerned with human services.
American with Disabilities Act (ADA)
The American with Disabilities Act provides the means by which Americans with disabilities can overcome barriers. According to the law, its purposes are to provide a clear and comprehensive national mandate for the elimination of discrimination against individuals with disabilities, as well as clear, strong, consistent, and enforceable set of standards addressing discrimination against individuals with disabilities.
Anxiety Disorders
Anxiety disorders cause intense feelings of anxiety and tension when there is no real danger. The symptoms cause significant distress and interfere with daily activities. Sufferers of anxiety disorders usually take extreme measures to avoid situations that provoke anxiety. The physical signs of anxiety are restlessness, irritability, disturbed sleep, muscle aches and pains, gastrointestinal distress, and difficulty concentrating. Anxiety disorders are often accompanied by the symptoms of depression and can lead to chronic anxiety.
Appeal
Any action a Medical Assistance eligible individual files with the Office of Administrative Hearings (OAH) contesting a denial of services decision made by the CSA or any action a provider files with OAH contesting a denial of a claim.
Area Agency on Aging (AAA)
Area Agency on Aging is the local agency that receives funds to care for the needs of older adults. Pennsylvania has 52 sub-state area agencies on aging. See PCA.
Assignment
A process in which a Medicare beneficiary agrees to have Medicare's share of the cost of a service paid directly, or assigned, to a doctor or other provider, and the provider agrees to accept the Medicare approved charge as payment in full. Medicare pays 80 percent of the cost and the beneficiary 20 percent, for most services. See participating physician.
Behavioral Health
Another term for mental health.
Behavior Modification
The application of conditioning techniques (rewards or punishments) to reduce or eliminate problematic behavior, or to teach people new responses.
Bipolar Disorder/Manic Depression
A serious mood disorder which involves extreme mood swings or highs (mania) and lows (depression); sometimes termed manic-depressive psychosis.
Borderline Personality
A highly unstable personality style characterized by intense personal relationship problems. Individuals with borderline personality often suffer from depression, anxiety, and the fear of being abandoned.
Capitation
A method for payment to providers, used in most managed care arenas. Unlike the older fee-for-service arrangement, in which the provider is paid per procedure, capitation involves a prepaid amount per month to the provider per covered member. The provider is then responsible for providing all contracted services (such as behavioral health) required by members of that group during that month for the fixed fee, regardless of the amount of charges incurred.
Care Management Team
The Care Management Team is a team of experienced mental health providers with doctoral-level supervision that is responsible for reviewing, coordinating and approving the mental health treatment. Inpatient hospital care residential treatment, partial hospitalization and intensive/traditional outpatient services must be approved in advance or at the time of admission by the Care Management Team.
Care Manager
The Care Manager is a mental health professional. He or she is responsible for reviewing, coordinating and approving the mental health treatment of individuals served by the Maryland Public Mental Health System. Inpatient hospital, residential treatment, partial hospitalization and intensive/traditional outpatient services must be approved in advance or at the time of admission by the Care Manager.
Carve-Outs
A payer strategy in which a payer separates, carves-out, a portion of the benefit, such as behavioral health, and hires a managed behavioral health program to provide these benefits.
Case Management
The monitoring and coordination of treatment rendered to patients with specific diagnosis or requiring high-cost or extensive services.
Case Mix
A measure of the mix of cases being treated by a particular health care provider that is intended to reflect the patients' different needs for resources. Case mix is generally established by estimating the relative frequency of various types of patients seen by the provider in question during a given time period and may be measured by factors such as diagnosis, severity of illness, utilization of services, and provider characteristics.
Categorically Needy
Persons whose Medicaid eligibility is based on their family, age or disability status. Persons not falling into these categories cannot qualify, no matter how low their income. The Medicaid statute defines over 50 distinct population groups as potentially eligible, including those for which coverage is mandatory in all states and those that may be covered at a state's option. The scope of covered services that states provide to the categorically needy is much broader than the minimum scope of services for the other, optional groups receiving Medicaid benefits. See medically needy.
Centers for Medicare & Medicaid Services (CMS)
The government agency within the Department of Health and Human Services which directs the Medicare and Medicaid programs, Titles XVIII and XIX of the Social Security Act, and conducts research to support those programs.
Center for Mental Health Services (CMHS)
Federal agency that provides leadership to (1) ensure the application of scientifically established findings and practice-based knowledge in the prevention and treatment of mental disorders; (2) improve access, reduce barriers, and promote high quality effective programs and services for people with, or at risk for these disorders, as well as for their families and communities; and (3) promote the rehabilitation of people with mental disorders. A source for federal block grants.
Chronic Care
Care and treatment rendered to individuals whose health problems are of a long-term and continuing nature. Rehabilitation facilities, nursing homes, and mental hospitals may be considered chronic care facilities.
Chronically Mentally Ill (CMI)
A term sometimes used to describe adults with serious and persistent mental illnesses. Currently, the term SMI, seriously mentally ill, is preferred when referring to the population. Individuals with psychiatric disabilities is also used frequently.
Clinical Psychologists
Mental health professionals who have earned a doctoral degree in psychology (either a Ph.D or a Psy.D, Doctor of Psychology) and have received extensive clinical training. They are trained in research, assessment, and the application of different psychological therapies. Clinical psychologists are concerned with the study, diagnosis, treatment, and prevention of mental and emotional disorders and disabilities.
Cognitive Behavior Therapy (CBT)
A form of psychological therapy that focuses on directly modifying both cognitive processes and behavior. CBT draws heavily on cognitive theory and research, as well as more traditional techniques.
Community Behavioral Health Corporation (CBH)
Community Behavioral Health Corporation, is the non-profit managed care organization that cares for the behavioral care for Medicaid recipients in Philadelphia County.
Community Mental Health Center (CMHC)
A mental health center usually serving an area which has scarce or nonexistent mental health services. Community Health Centers attempt to coordinate federal, state and local resources into a single organization capable of delivering both health and related social services to a defined population. While such a center may not directly provide all types of health care, it usually takes responsibility to arrange all medical services needed by its patient population.
Complaint
Any oral written action a consumer in the population group or a provider files with the health organization.
Consumer
A consumer is an individual, or parent of a minor child, who received mental health services.
Copayment
A form of cost sharing in which a fixed amount of money is paid by the insured for each health care service provided.
Core Service Agency - (CSA)
Local management entity for public mental health services within a jurisdiction. Agency responsibilities include planning, providing for service provision according to locally determined needs, and monitoring service delivery and evaluating service outcomes. CSAs are agents of county or City government and may be a county department, quasi government body or private non-profit corporation. The definition of cognitive behavioral therapy should read: A form of psychological therapy that focuses on directly modifying both cognitive processes and behavior. CBT draws heavily on cognitive theory and research, as well as more traditional techniques of behavior modification.
Crisis Response Center (CRC)
Crisis Response Centers are places that offer 24-hour emergency psychiatric services.
Deductible
The amount of loss or expense that must be incurred by an insured or otherwise covered individual before an insurer will assume any liability for all or part of the remaining cost of covered services. Deductibles may be either fixed-dollar amounts or the value of specified services, such as two days of hospital care or one physician visit. Deductibles are usually tied to some reference period over which they must be incurred, e.g., $100 per calendar year, benefit period, or spell of illness.
Delaware Valley Mental Health and Aging Advocacy Committee (DVMHAAC)
Delaware Valley Mental Health and Aging Advocacy Committee is a non-profit organization that advocates for the mental health needs of older adults in the Delaware Valley region of Pennsylvania.
Depression
A mood disorder involving disturbances in emotion (excessive sadness), behavior (apathy and loss of interest in usual activities), cognition (distorted thoughts of hopelessness and low self-esteem), and body function (fatigue, loss of appetite). Symptoms extend into many parts of an individual's life and include lack of interest in daily activities, decreased motivation, feelings of worthlessness, and sometimes suicidal thoughts.
Diagnostic and Statistical Manual of Mental Disorders(DSM-IV R)
Diagnostic and Statistical Manual of Mental Disorders, 4th edition, revised. Manual of standard definitions of clinical diagnostic terms. Produced by the American Psychiatric Association.
Drug Utilization Review
Either present or retrospective management of an insured population's drug use. The goal of such management is to reduce the cost of drug therapies. Methods used include: substituting generic drugs for name brands, using a formulary to limit the drugs that can be prescribed, requiring co-payments for prescriptions, and encouraging the use of drugs that will trigger rebates or discounts.
Dual Eligibles
Dual eligibles are individuals who are entitled to Medicare Part A and/or Part B and are eligible for some form of Medicaid benefit. See QMB, SLMB, QDWI.
Durable Medical Equipment
Prescribed medical equipment, such as a wheelchair or respirator, that can be used for an extended period of time.
Early and Periodic Screening, Diagnostic and Treatment Program (EPSDT)
A federally funded program to provide preventive health care to poor children eligible for Medicaid. One of the essential purposes of the program is to ensure that eligible children are screened for potential health problems, vision, hearing, and dental problems on a regular basis so that problems can be identified and treated early.
Eligibility Verification System (EVS)
To determine if a recipient has already selected a managed care organization.
Employee Retirement Income Security Act (ERISA)
A Federal Act, passed in 1974, that established new standards and reporting/disclosure requirements for employer-funded pension and health benefit programs. To date, self-funded health benefit plans operating under ERISA have been held to be exempt from state insurance laws.
Enrollee
Any person eligible, as either a subscriber or a dependent, in an employee benefit plan.
Family Therapy
A therapeutic method which involves assessment and treatment with all immediate family members present. This therapy places emphasis on the family as a system rather than focusing on one person who might be deemed the identified patient.
Formulary
An approved list of prescription drugs; a list of selected pharmaceuticals and their appropriate dosages felt to be the most useful and cost effective for patient care. Organizations often develop a formulary under the aegis of a pharmacy and therapeutics committee. In HMOs, physicians are often required to prescribe from the formulary.
Gatekeeper
The primary care physician or his/her staff in managed care organizations who determines whether the presenting patient needs to see a specialist or requires other non-routine services. The goal is to guide the patient to appropriate services while avoiding unnecessary and costly referrals to specialists. In behavioral health this may be a case manager.
Gatekeeper Program
Programs in which the community takes an active role in watching out for its elderly population. It involves training people who have regular contact with elderly to notice signs of deterioration and how to refer for social services.
Global Assessment of Functioning (GAF) Scale, DSM IV
The reporting of overall function on Axis V is performed using the Global Assessment of Functioning (GAF) Scale. The GAF scale may be particularly useful in tracking the clinical progress of individuals in global terms, using a single measure. The GAF scale is to be rated with respect only to psychological and occupational functioning.
Health Care Financing Administration
Now known as the Centers for Medicare & Medicaid Services (CMS). The government agency within the Department of Health and Human Services which directs the Medicare and Medicaid programs, Titles XVIII and XIX of the Social Security Act, and conducts research to support those programs.
Healthy Horizons
A two-part special medical program in Pennsylvania for persons age 65 or over, or persons with a disability. It will help pay for Medicare premiums and deductibles who qualify.
Health Maintenance Organization (HMO)
An HMO is a prepaid organization that provides health care to voluntary enrolled members in return for a preset amount of money on a per member per month basis. They include a health plan that places at least some of the providers at risk for medical expenses, and use gatekeepers, usually primary care physicians, to restrict services.
Hill-Burton
Coined from the names of the principal sponsors of the Public Law 79-725, the Hospital Survey and Construction Act of 1946. This program provided Federal support for the construction and modernization of hospitals and other health facilities. Hospitals that have received Hill-Burton funds incur an obligation to provide a certain amount of charity care.
HUD (U.S. Housing and Urban Development)
A federal agency responsible for housing programs and Section 8 housing, a program of vouchers for housing for the disabled.
Hypomania
An episode in which the individual experiences a mild form of mania (emotional highs, scattered thoughts, over-activity). Such an episode does not markedly impair an individual's social and vocational functioning, and does not necessarily indicate the presence of bipolar disorder.
Independent Practice Association (IPA)
An IPA is an association of physicians and other health care providers, including hospitals, who contract with an HMO to provide services to enrollees, but usually still see non-HMO patients and patients from other HMOs.
Individuals with Disabilities Education Act (IDEA)
The 1997 Individuals With Disabilities Education Act, signed into law by President Clinton, aims to strengthen academic expectations and accountability for the nation's 5.4 million children with disabilities, and bridge the gap that has too often existed between what those children learn and the regular curriculum.
Inpatient
A person who has been admitted at least overnight to a hospital or other health facility, which is therefore responsible for his/her room and board, for the purpose of receiving diagnostic treatment or other health services.
Intermediate Care Facility (ICF)
An institution which is licensed under state law to provide on a regular basis, health-related care and services to individuals who do not require the degree of care or treatment which a hospital or skilled nursing facility is designed to provide. Public institutions for care of the mentally retarded or people with related conditions are also included in the definition. The distinction between health-related care and services and room and board has often proven difficult to make but is important because ICFs are subject to quite different regulations and coverage requirements than institutions which do not provide health-related care and services.
Intensive Case Management (ICM)
See case management.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
A peer review organization which surveys, evaluates, and accredits hospitals.
Licensed Certified Social Worker (LCSW)
Some states require social workers to be licensed, while certification and registration, whether offered by the state or by a professional organization, is usually voluntary. Holding a license generally requires the licensee to adhere to a code of ethics or professional conduct. If this code is violated, the license can be revoked or other disciplinary actions taken.
Long Term Care
A set of health care, personal care and social services required by persons who have lost, or never acquired, some degree of functional capacity (e.g., the chronically ill, aged, disabled, or retarded) in an institution or at home, on a long-term basis. The term is often used more narrowly to refer only to long-term institutional care such as that provided in nursing homes, homes for the retarded and mental hospitals. Ambulatory services such home health care, which can also be provided on a long-term basis, are seen as alternatives to long-term institutional care.
Managed Care
Managed Care is a method of financing and delivering health care for a set fee using a network of physicians and other health care providers who have agreed to the set fees.
Managed Care Organization (MCO)
A managed care organization is a health care plan designed to provide medical services through groups of doctors, hospital and specialty providers. Examples of managed care organizations or plans are Health Maintenance Organizations, Community Health Centers and Preferred Provider Organizations.
Mania
A symptom of bipolar disorder characterized by exaggerated excitement, physical overactivity, and profuse and rapidly changing ideas (scattered or tangential thoughts). A person in a manic state feels an emotional high and generally follows their impulses.
Medicaid (Title XIX)
A Federally aided, state-operated and administered program which provides medical benefits for certain indigent or low-income persons in need of health and medical care. The program, authorized by Title XIX of the Social Security Act, is basically for the poor. It does not cover all of the poor, however, but only persons who meet specified eligibility criteria. Subject to broad Federal guidelines, states determine the benefits covered, program eligibility, rates of payment for providers, and methods of administering the program.
Medicaid Only Dual Eligibles
These individuals are entitled to Medicare Part A and/or Part B and are eligible for full Medicaid benefits. They are not eligible for Medicaid as a QMB, SLMB, QDWI, QI-1, or QI-2. Typically, these individuals need to spend down to qualify for Medicaid or fall into a Medicaid eligibility poverty group that exceeds the limits. Medicaid provides full Medicaid benefits and pays for Medicaid services provided by Medicaid providers, but Medicaid will only pay for services also covered by Medicare if the Medicaid payment rate is higher than the amount paid by Medicare, and, within this limit, will only pay to the extent necessary to pay the beneficiary's Medicare cost-sharing liability. Payment by Medicaid of Medicare Part B premiums is a state option; however, states may not receive FFP for Medicaid services also covered by Medicare Part B for certain individuals who could have been covered under Medicare Part B had they been enrolled. Federal financial participation (FFP) equals the Federal medical assistance percentage (FMAP).
Medical Assistance (MA)
A government program that pays medical costs for very low income people.
Medical Necessity
The purpose of Medical Necessity Criteria is to assist Care Managers (masters or doctoral level psychologists, social workers, or licensed psychiatric nurses with over five years of mental health experience) and board certified psychiatrists, during a clinical review to determine the most appropriate level of care and intensity of services and individual requires. Referral guidelines are of additional assistance in determining a particular program or services and the nature of those services within the specific level of care identified (e.g., crisis services might be provided within the supported community residential, intensive outpatient or traditional outpatient level of care). Referral guidelines are written for specific programs or services and are not meant to be all encompassing or to infer other services might not be authorized based upon individual need.
Medically Needy
Persons who are categorically eligible for Medicaid and whose income, less accumulated medical bills, is below state income limits for the Medicaid program. Often seen as a problem among the working poor or among the senior population.
Medicare (Title XVIII)
A U.S. health insurance program for people aged 65 and over, for persons eligible for social security disability payments for two years or longer, and for certain workers and their dependents who need kidney transplantation or dialysis. Monies from payroll taxes and premiums from beneficiaries are deposited in special trust funds for use in meeting the expenses incurred by the insured.
Medicare has two basic coverages: Part A, which pays for hospitalization costs; and Part B, which pays for physician services, lab and x-ray services, durable medical equipment, and outpatient and other services.
Medigap Policy
A private health insurance policy offered to Medicare beneficiaries to cover expenses not paid by Medicare. Medigap policies are strictly regulated by federal rules. Also known as Medicare supplemental insurance.
Mental Health Services
Comprehensive mental health services, as defined under some state laws and federal statutes, include: inpatient care, outpatient care, day care, and other partial hospitalization and emergency services; specialized services for the mental health of children; specialized services for the mental health of the elderly; consultation and education services; assistance to courts and other public agencies in screening catchment area residents; follow-up care for catchment area residents discharged from mental health facilities or who would require inpatient care without such halfway house services; and specialized programs for the prevention, treatment and rehabilitation of alcohol and drug abusers.
Morbidity
The extent of illness, injury, or disability in a defined population. It is usually expressed in general or specific rates of incidence or prevalence.
Multiple Personality Disorder/Dissociative Disorder
A rare disorder marked by the appearance, within one person, of two or more distinct personalities, each with its own name, history, and traits. The alternative personalities are usually fully integrated with consistent patterns of behavior and attitudes.
National Alliance for the Mentally Ill (NAMI)
The mission of the National Alliance for the Mentally Ill is to eradicate mental illness and improve the quality of life of those affected by these diseases. NAMI members are committed to increasing access to community based services including housing and rehabilitation for mentally ill people. Most NAMI members have used up their private funds and insurance and must rely on the public mental health system.
National Institute for Mental Health (NIMH)
The federal institute that conducts and promotes research and public education regarding health issues. Part of the National Institutes of Health (NIH).
National Mental Health Association (NMHA)
The National Mental Health Association, through its national office and more than 330 affiliates nationwide, is dedicated to improving the mental health of all individuals and achieving victory over mental illnesses.
Nursing Home
Includes a wide range of institutions which provide various levels of maintenance and personal or nursing care to people who are unable to care for themselves and who have health problems which range from minimal to very serious. The term includes free-standing institutions, or identifiable components of other health facilities which provide nursing care and related services, personal care, and residential care. Nursing homes include skilled nursing facilities and extended care facilities but not boarding homes.
Office of Mental Health/ Mental Retardation (OMH/MR)
Office of Mental Health/ Mental Retardation is the city agency responsible for programs for those with mental illness or developmental disabilities.
Outpatient
A patient who is receiving ambulatory care at a hospital or other facility without being admitted to the facility. Usually, it does not mean people receiving services from a physician's office or other program which also does not provide inpatient care.
Outpatient Mental Health Center (OMHC)
A clinic which provides outpatient mental health services. Also known as CMHC, Community Mental Health Center.
Outpatient Services
Community mental health clinics, mobile treatment, psychiatric rehabilitation, office based practices, clinics, therapeutic nurseries, EPSDT, or other community services.
Panic Attack/Panic Disorders
A stress-related, brief feeling of intense fear and impending doom or death, accompanied by intense physiological symptoms such as rapid breathing and pulse, sweaty palms, smothering sensations, shortness of breath, choking sensations, and dizziness. These panic attacks can happen very frequently and leave the individual emotionally drained. Sufferers often live in fear of having another panic attack and develop avoidance behaviors. Sufferers often consult physicians many times thinking they are having a heart attack or asthma attack.
Participating Physician
A physician under contract with a HMO who has agreed to provide services for a set payment, or who agrees to other arrangements, or who agrees to provide services to a group or defined patients. Also refers to a provider or physician who signs an agreement to accept assignment on all Medicare claims for one year.
Personality disorders
Psychological disorders in which maladaptive personality patterns cause personal distress or inability to get along with others. These inflexible ways of interacting often remain constant despite aging, different environments, and medication, and often cause serious difficulties for the disordered individual. See also borderline personality.
Philadelphia Corporation for Aging (PCA)
Philadelphia Corporation for Aging, the area agency on aging for Philadelphia.
Physician Hospital Association (PHO)
A Physician Hospital Association is an organization that includes hospitals and physicians contracting with one or more health care organizations, insurance plans, or directly with employers to provide health care services.
PL 99-660
State Comprehensive Mental Health Services Plan Act of 1986. Federal Law that mandated that all states develop plans for a comprehensive community-based mental health service for individuals with serious mental illness.
Point of Service Plan (POS)
A POS is a health plan whose members can choose their services when they need them, either in the or from a provider outside the HMO at some cost to the member. Or a plan in which the primary provider directs services and referrals.
Pre-Admission Screening and Annual Resident Review (PASARR)
The Omnibus Reconciliation Act of 1987. (OBRA '87) requires pre-admission screening and annual resident review of individuals with mental illness or mental retardation and related conditions, who are applicants to or residents of nursing facilities certified for Medicaid, regardless of the source of payment for Nursing Facilities services.
Preferred Provider Organization (PPO)
A variation of traditional fee-for-service care arrangements. A group of physicians, dentists, and/or hospitals and other practitioners contracts with a payer to provide employees with services at competitive rates. The employee is not penalized or prevented from using his or her regular physician, even if that physician does not participate in the PPO; in such cases, however, the participant usually pays a higher fee or co-payment.PPOs usually provide incentives for provider participation, such as a competitive rate structure or the implication of increased volume. In addition, PPOs generally use primary care physicians to assure that hospitalization occurs only when absolutely necessary, with extensive concurrent utilization review.
Primary Care Provider (PCP)
A Primary Care Provider such as a family practitioner, general internist, pediatrician and sometimes an ob/gyn. Generally, a PCP supervises, coordinates, and provides medical care to members of a plan. The PCP may initiate all referrals for specialty care. In behavioral health this may be done by an authorized case manager.
Projects for Assistance in Transition from Homelessness (PATH)
This is a formula grant authorized by the Stewart B. McKinney Homeless Assistance Amendments Act of 1990 to provide community-based services for people with serious mental illness who are homeless or at imminent of becoming homeless.
Protection and Advocacy (P&A)
The process of protecting mental health system consumers from abuse and neglect and assuring that their rights as citizens and recipients of care are fully respected. P&A can also refer to the Protection and Advocacy for Mentally Ill Individuals Act of 1986 which provided federal funds for each state to establish programs designed to protect and advocate for the rights of people with a mental illness.
Provider Organization
A practice, clinic, mental health center, hospital, or other organization that is employed by managed health programs to provide treatment services.
Psychiatric Nurses
These core mental health professionals, who have earned a Masters degree in Psychiatric Nursing, typically have extensive training in psychopharmacology and counseling.
Psychopharmacology
The management of psychiatric illness using medication.
Qualified Medicare Beneficiaries (QMBs) without other Medicaid (QMB Only)
These individuals are entitled to Medicare Part A, have income of 100 percent of the Federal poverty level (FPL) or less and resources that do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for full Medicaid. Medicaid pays their Medicare Part A premiums, if any, Medicare Part B premiums, and, to the extent consistent with the Medicaid State plan, Medicare deductibles and coinsurance for Medicare services provided by Medicare providers. Federal financial participation (FFP) equals the Federal medical assistance percentage (FMAP).
Qualified Disabled and Working Individuals (QDWIs)
These individuals lost their Medicare Part A benefits due to their return to work. They are eligible to purchase Medicare Part A benefits, have income of 200 percent of the Federal poverty level (FPL) or less and resources that do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for Medicaid. Medicaid pays the Medicare Part A premiums only. Federal financial participation (FFP) equals the Federal medical assistance percentage (FMAP).
Qualifying Individuals (1) (QI-1s)
This group is effective 1/1/1998 - 12/31/2002. There is an annual cap on the amount of money available, which may limit the number of individuals in the group. These individuals are entitled to Medicare Part A, have income of 120 - 135 percent of the Federal poverty level (FPL), resources that do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for Medicaid. Medicaid pays their Medicare Part B premiums only.FFP equals the Federal medical assistance percentage (FMAP) at 100 percent.
Qualifying Individuals (2) (QI-2s)
This group is effective 1/1/1998 - 12/31/2002. There is an annual cap on the amount of money available, which may limit the number of individuals in the group. These individuals are entitled to Medicare Part A, have income of 135 - 175 percent of the Federal poverty level (FPL), resources that do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for Medicaid. Medicaid pays only a portion of their part B premiums ($1.07 in 1998).FFP equals the Federal medical assistance percentage (FMAP) at 100 percent.
QMBs with full Medicaid (QMB Plus)
These individuals are entitled to Medicare Part A, have income of 100 percent of the Federal poverty level (FPL) or less and resources that do not exceed twice the limit for SSI eligibility, and are eligible for full Medicaid benefits. Medicaid pays their Medicare Part A premiums, if any, Medicare Part B premiums, and, to the extent consistent with the Medicaid State plan, Medicare deductibles and coinsurance, and provides full Medicaid benefits. Federal financial participation (FFP) equals the Federal medical assistance percentage (FMAP).
Residential Services
Care given in a residential crisis bed, a respite bed, a therapeutic group home, a group home, or residential rehabilitation program.
Schizophrenia
A psychiatric disorder marked by some or all of these symptoms: delusions, hallucinations, incoherent word associations, inappropriate emotions, or lack of emotions. It is characterized by serious disturbances of thought and perception which cannot be attributed to brain damage. A separation or loosening of associations, as between feelings and thoughts, is believed to underlie the unusual behavior that is exhibited.
Section 1115 Medicaid Waiver
Section 1115 of the Social Security Act grants the secretary of Health and Human Services broad authority to waive certain laws relating to Medicaid for the purpose of conducting pilot, experimental or demonstration projects which are likely to promote the objectives of the program. Section 1115 demonstration waivers allow states to change provisions of their Medicaid programs, including: eligibility requirements, the scope of services available, the freedom to choose a provider, a provider's choice to participate in a plan, the method of reimbursing providers, and the statewide application of the program.
Section 1915(b) Medicaid Waiver
Section 1915(b) waivers allow states to require Medicaid recipients to enroll in HMOs or other managed care plans in an effort to control costs. The waivers allow states to: implement a primary care case-management system; require Medicaid recipients to choose from a number of competing health plans; provide additional benefits in exchange for savings resulting from recipients' use of cost-effective providers; and limit the providers from which beneficiaries can receive non-emergency treatment. The waivers are granted for two years, with two-year renewals. Often referred to as a freedom-of-choice waiver.
Self Insured
When an employer pays medical claims directly without buying coverage from an insurance company. Self insured companies are exempt from state insurance regulations, and instead are governed by the federal ERISA laws.
Seriously Mentally Ill Persons (SMI)
Sometimes used to describe adults with serious and persistent mental illnesses. Another term often used is individuals with psychiatric disabilities.
Service Type
Care in a psychiatric unit in an acute care hospital, residential services, outpatient mental health clinics, mobile treatment, psychiatric rehabilitation, individual therapy services,or other outpatient services, and ancillary services (laboratories, pharmacies).
Skilled Nursing Facility (SNF)
A nursing care facility participating in the Medicaid and Medicare programs which meets specified requirements for services, staffing and safety.
SLMBs with full Medicaid (SLMB Plus)
These individuals are entitled to Medicare Part A, have income of 100 - 120 percent Federal poverty limit (FPL) and resources that do not in exceed twice the limit for SSI eligibility, and are eligible for full Medicaid benefits. Medicaid pays their Medicare Part B premiums and provides full Medicaid benefits. Federal financial participation (FFP) equals the Federal medical assistance percentage (FMAP).
Sole Source Provider
Government contract for services awarded without a competitive bidding process because there is judged to be no alternative provider.
Specified Low-Income Medicare Beneficiaries (SLMBs) without other Medicaid (SLMB Only)
These individuals are entitled to Medicare Part A, have income of 100 - 120 percent Federal poverty limit (FPL) and resources that do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for Medicaid. Medicaid pays their Medicare Part B premiums only. Federal financial participation (FFP) equals the Federal medical assistance percentage (FMAP).
State Mental Hospital (SMH)
A State run institution serving mental health consumers.
[U.S.] Substance Abuse & Mental Health Services Administration (SAMHSA)
The mission of SAMHSA is to provide, through the U.S. Public Health Service, a national focus for the Federal effort to promote effective strategies for the prevention and treatment of addictive and mental disorders.SAMHSA is primarily a grant-making organization, promoting knowledge and scientific state-of-the-art practice. SAMHSA strives to reduce barriers to high quality, effective programs and services for individuals who suffer from, or are at risk for, these disorders, as well as for their families and communities.
Supported Living (SL)
This initiative is designed to increase housing options available to persons with serious mental illness. Through supported living programs, individuals with psychiatric disabilities may access an array of flexible services and supports to enable them to live in the housing of choice and to become participating members of the community.
Supported Housing (SH)
See Supported Living.
U.S. Social Security Administration (SSA)
Federal governnent office that runs the social security program.
Social Security Disability Insurance (SSDI)
A disability program of the Social Security Administration. A person must be considered medically disabled, and have worked and paid social security taxes (F.I.C.A.) for a specific number of years to be eligible.
Social Security Disability Insurance (SSDI)
A disability program of the Social Security Administration. A person must be considered medically disabled, and have worked and paid social security taxes (F.I.C.A.) for a specific number of years to be eligible.
Supplemental Security Income (SSI)
A disability program of the Social Security Administration. A person must be considered medically disabled, have little or no income or resources to be eligible.
TITLE XVIII - Medicare
See Medicare, TITLE XVIII.
TITLE XIX - Medicaid
See Medicaid.
Utilization Management (UM)
Evaluation of the necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities. In a hospital, this includes review of the appropriateness of admissions, services ordered and provided, length of a stay, and discharge practices, both on a concurrent and retrospective basis. Utilization review can be done by a peer review group, or a public agency.
Underinsured
People with public or private insurance policies that do not cover all necessary health care services, resulting in out-of-pocket expenses that exceed their ability to pay.
Uninsured
People who lack public or private health insurance.
Mental Health/Aging Advocacy Project | a project of the Mental Health Association of SE PA | 1211 Chestnut Street | Philadelphia, PA 19107 | 215-751-1800, ext. 266 | e-mail: tvolkert@mhasp.org | www.mhaging.org
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